Scrutiny of extent of axillary node dissection for patients with primary breast cancer

Background: Carcinoma of the breast is the most common of non-skin malignancies in women and is second to lung cancer is a cause of cancer deaths. A woman who lives to age 90 has a one in eight chance of developing breast cancer. It is as ironic and tragic that a neoplasm arising in an exposed organ, readily accessible to self-examination and clinical surveillance, continues to exact such a heavy toll. The aim of the study: To determine, if differences in the extent of axillary node dissection would alter the number of reported positive nodes, to emphasize the presence and importance of dissecting the inter pectoral node (Rotter’s Node) in Modified Radical Mastectomy. Materials and methods: This study was conducted in the Department of General Surgery, Government Stanley Medical College, Chennai in 2018. Patients were evaluated according to NCCN guidelines and were subjected to Modified Radical Mastectomy for whomsoever it was needed. 32 cases underwent Modified Radical Mastectomy with complete axillary dissection (level I/II/III and inter pectoral node) according to the identical procedure. The dissection was carried out in all patients, irrespective of whether they had palpable nodes or not clinically. Results: An average of 13 lymph nodes was examined per case (range: 8−20). Axillary lymph node involvement was found in 56% of the cases (18/32). Of the 18 cases, 83% (n = 15) had involvement of level I/II nodes only, and 16% (n = 3) had positive ALN in levels III and, or, inter pectoral nodes, in addition to the level I/II. Involvement of lymph nodes in level III and inter pectoral nodes without a level I metastasis was not found. By the inclusion of level III to a level I/II dissection, two cases (11%) was converted from one to three positive nodes (pN1) to ≥4 positive nodes (pN2). Involvement Rosy Adhaline Selvi, Manimegalai. Scrutiny of extent of axillary node dissection for patients with primary breast cancer. IAIM, 2019; 6(3): 212-216. Page 213 of lymph nodes in level III was found in 3 cases (16%) 10/32 cases (31%) had ≥4 positive nodes who required adjuvant therapy. Conclusion: Variations in the level of axillary node dissection for breast cancer which includes the inter pectoral and level III nodes can result in significant changes in the number of positive axillary nodes stepping up the pathologic nodal status from pN1 to pN2. This can potentially bias adjuvant therapy recommendations if treatment decisions are based on this prognostic factor.

Predictive Factors Affecting Axillary Lymph Node Metastasis in Patients with Invasive Breast Carcinoma of 1 cm or Less

PURPOSE: Although screening MMG leads to increase of early small breast cancer, axillary lymph node metastasis is still an important prognsotic factor in these patients. The aim of this study is to evaluate the incidence and predictors for axillary lymph node metastasis in patients with invasive breast carcinoma of 1 cm or less. METHODS: A retrospective analysis was made of 144 patients who underwent resection of primary tumor and axillary procedures between January 1999 and August 2009 for breast cancer of 1 cm or less in size. Patients were divided into two groups according to axillary node metastasis and clinicopathologic factors including age, palpable mass during physical examination, location of tumor, multifocality, tumor size, histologic type, extensive in situ component, histologic grade, nuclear grade, lymphovascular invasion, hormonal receptor status, and C-erbB-2 status were compared. RESULTS: Twenty-eight (19.4%) patients of all 144 patients had metastasis in the axillary lymph node. Three variables such as multifocality (P=0.023), histologic high grade (P=0.033), presence of lymphovascular invasion (P=0.002) were found to be significant in univariate analysis. In a multivariate logistic regression analysis, however, multifocality (P=0.022) and presence of lymphovascular invasion (P=0.007) were independent predictors of axillary lymph node metastasis. CONCLUSION: The incidence of axillary lymphnode metastasis of breast cancer 1 cm or less in size was 19.4%. Although the size of invasive breast carcinoma is less than 1 cm, if the tumor presented lymphovascular invasion or multifocality, axillary lymph node dissection might prove better than sentinel node biopsy.

The Timing of Recurrence Dependent on Menopausal Status after Surgery for Breast Cancer

PURPOSE: This study was aimed at evaluating the timing of clinical recurrence after surgical removal of the primary tumor. METHODS: The hazard rate for recurrence during the first 5 years after surgery was studied in 1,225 female patients from 1995 to 2003 at Kyungpook National University Hospital. Subset analyses were performed according to menopausal status and axillary lymph node involvement. RESULTS: The group of premenopausal women has one peak hazard rate in the 18~24 month period after surgery, while that of postmenopausal women has two peaks at 18~24 months and 42~48 months. The hazard rate of node positive group is much higher than node negative group at all periods. In the premenopausal group, patients with less than 3 node metastases have a peak hazard rate at about 18~24 months, while those with more than 4 lymph node metastases have that in 6~12 months. In the postmenopausal group, patients with less than 3 node metastases have the peak hazard rate at 18~24 months, while more than 4 lymph node metastases have two peaks at 18~24 months and 42~48 months. CONCLUSION: Both premenopausal and postmenopausal groups similarly show the peaked hazard rate of recurrence at about 2 years after surgery. In premonopausal young women, the status of nodal metastasis affects early recurrence, while in postmenopausal women, more nodal metastasis related with late recurrence at about 45 months. Menopausal status according to axillary node involvement shows the different recurrence pattern.

Prognosis of Breast Cancer Patients with Ten or More Positive Lymph Nodes

PURPOSE: The most important prognostic factor in patients with operable breast cancer is lymph node involvement. The 6th edition of AJCC categorizes metastasis to more than 10 nodes as N3, or stage IIIc. Such patients have a high risk of recurrence and death. The purpose of this study was to evaluate the prognosis of these N3 patients. METHODS: Between 1991 and 2004, 141 patients with 10 or more positive lymph nodes were treated at our institution, and we retrospectively reviewed their medical records. We analyzed patient age, tumor size, number of metastatic lymph nodes, hormone receptor status, C-erb-B2 status, and treatment modality. Survival was calculated using the Kaplan-Meier method on SPSS 12.0 software. RESULTS: The median follow-up duration was 55.0 months (range 3~182 months); 78 patients had recurrence, and 44 patients died. The 5-year disease-free survival and 5-year overall survival rates were 49.4% and 64.6%, respectively. The only prognostic factor for disease-free survival was tumor size. In patients with tumors less than 2 cm in size, the 5-year disease-free survival was 68.9%, while the 5-year disease-free survival was 27.7% in patients with tumors larger than 5 cm. Hormonal receptor status, C-erb-B2 status, number of metastatic lymph nodes, and treatment modality were statistically insignificant in predicting disease-free survival. None of these factors was significant for predicting overall survival, either. CONCLUSION: The 5-year disease-free survival rate was 49.4%, and it was influenced only by tumor size. Adjuvant chemotherapy and adjuvant radiotherapy were not independent factors predicting survival. Early breast tumor detection is important in N3 breast cancer patients.

The Predictors of Axillary Node Metastasis in 2 cm or Less Breast Cancer Univariate and Multivaritate Analysis / 한국유방암학회지

BACKGROUND: Axillary noed involvement is the single most important prognostic variable in patients with breast cancer. If axillary lymph node status of breast cancer patients could be accurately predicted from basic clinical information and from characteristics of their primary tumors, many patients could be spared axillary lymph node dissection. With the availability of numerous histologic prognosticators and new immunochemical prognostic indicators, it is time to consider eliminating routine node dissection for lesions more advanced than duct carcinoma in situ (DCIS). MATERIALS AND METHODS: Two hundred sixty-three patients with T1 invasive breast cancer were evaluated. All underwent axillary dissection, and the pathologic status of the nodes was known. The parameters of the primary tumor evaluated included age, size, family history, tumor palpability, nuclear and histological grade, hormone receptor status, lymphatic vessel invasion (LVI), and various tumor markers (bcl-2, cathepsinD, c-erbB2, E-cadherin, p53). RESULTS: Approximately 31.1% of the 656 patients with T1 breast carcinoma had axillary node metastasis. Four factors were identified as significant predictors of node metastasis: age35 or less (p=0.01), lymphatic vessel invasion (p<0.01), tumor palpability(p=0.02), and tumor size (p<0.01). However, independent predictors of lymph node metastasis in the multivariate logistic regression analyses were tumor size (p=0.04) and LVI (P=0.03). CONCLUSION: In conclusion, characteristics of the primary tumor can help assess the risk for axillary lymph node metastases. Selected patients who have 1cm or less without lymphatic vessel invasion considered to be at minimal risk of axillary node metastasis and might spared routine axillary dissection.